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draft Transaction Return PS of country A 2.16.840.1.113883.3.1937.777.11.4.12

Data Set epSOS Data Set 2.16.840.1.113883.3.1937.777.11.1.1

Name Id
draft Return PS of country A 2.16.840.1.113883.3.1937.777.11.4.12
Version / effective date Expiration date
2012‑05‑02
Description
HP A responds by sending the PS to HP B
Name Details [‑]
folder draft Patient Data 1 … 1 Mandatory
epsos-dataelement-5
Id epsos-dataelement-5 (2013‑05‑31)
Cardinality 1 … 1 Mandatory

Description Information about the patient
target Used by 10 transactions, one template, inherited 0 times
 
folder draft Identification 1 … 1 Mandatory
epsos-dataelement-6
Id epsos-dataelement-6 (2013‑05‑31)
Cardinality 1 … 1 Mandatory

Description Country ID, unique for the patient in that country. Example: ID for United Kingdom patient
target Used by 8 transactions, one template, inherited 0 times
 
draft National Health Care patient ID (country of affiliation) 1 … 1 Mandatory
epsos-dataelement-7
Id epsos-dataelement-7 (2013‑05‑31)
Cardinality 1 … 1 Mandatory

Description Country ID from the country of origin, unique for the patient in that country. Example: ID for United Kingdom patient
Value Domain Identifier
Example
NL-Burgerservicenummer
999999512
Example
UK-NHS Number
943 476 5919
target Used by 8 transactions, one template, inherited 0 times
 
draft National Health Care patient ID (country of treatment) 0 … 0 Not present
epsos-dataelement-234
Id epsos-dataelement-234 (2013‑11‑25 12:03:28)
Cardinality 0 … 0 Not present

Description Country ID given in the country of treatment, unique for the patient in that country. Identifier that identifies that patient within the country B eHealth Infrastructure.
Value Domain Identifier
target Used by 3 transactions, one template, inherited 0 times
 
draft Other Identifier 0 … *
epsos-dataelement-235
Id epsos-dataelement-235 (2013‑11‑25 12:06:30)
Cardinality 0 … *

Description Other identifiers than the national health care patient IDs from either the country of affiliation or the country of treatment
Value Domain Identifier
target Used by 5 transactions, one template, inherited 0 times
 
folder draft Personal Information 1 … 1 Mandatory
epsos-dataelement-8
Id epsos-dataelement-8 (2013‑05‑31)
Cardinality 1 … 1 Mandatory

Description Personal information about the patient
target Used by 8 transactions, one template, inherited 0 times
 
folder draft Full Name 1 … 1 Mandatory
epsos-dataelement-9
Id epsos-dataelement-9 (2013‑05‑31)
Cardinality 1 … 1 Mandatory

Description The full name of the patient
target Used by 8 transactions, one template, inherited 0 times
 
draft Given name 1 … 1 Mandatory
epsos-dataelement-12
Id epsos-dataelement-12 (2013‑05‑31)
Cardinality 1 … 1 Mandatory

Description The Name of the patient (Example: John). This field can contain more than one element
Value Domain String
Example John
target Used by 8 transactions, one template, inherited 0 times
 
draft Family Name/Surname 1 … 1 Mandatory
epsos-dataelement-13
Id epsos-dataelement-13 (2013‑05‑31)
Cardinality 1 … 1 Mandatory

Description This field can containe more than one element.
Value Domain String
Example Español Smith
target Used by 8 transactions, one template, inherited 0 times
 
draft Prefix 0 … 1
epsos-dataelement-263
Id epsos-dataelement-263 (2013‑11‑27 11:44:16)
Cardinality 0 … 1

Value Domain String
target Used by 5 transactions, one template, inherited 0 times
 
draft Suffix 0 … 1
epsos-dataelement-264
Id epsos-dataelement-264 (2013‑11‑27 11:44:29)
Cardinality 0 … 1

Value Domain String
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Date of Birth 1 … 1 Mandatory
epsos-dataelement-10
Id epsos-dataelement-10 (2013‑05‑31)
Cardinality 1 … 1 Mandatory

Description The date of birth of the patient. This field may contain only the year if day and month are not available
Value Domain Date
Property
Timestamp precision
day, month and year
Example 091/01/2009
target Used by 8 transactions, one template, inherited 0 times
 
draft Gender 0 … 1
epsos-dataelement-11
Id epsos-dataelement-11 (2013‑05‑31)
Cardinality 0 … 1

Description It must contained a recognized valid value for this field.
Value Domain Code
Choice list
Concept List

Value Set epSOSAdministrativeGender (version DYNAMIC)
Example M
target Used by 8 transactions, one template, inherited 0 times
 
folder draft Contact Information 0 … *
epsos-dataelement-26
Id epsos-dataelement-26 (2013‑06‑03)
Cardinality 0 … *

Description Contact information of the patient, including information of the contacts of the patient.
target Used by 5 transactions, one template, inherited 0 times
 
folder draft Address 0 … *
epsos-dataelement-27
Id epsos-dataelement-27 (2013‑06‑03)
Cardinality 0 … *

Description Address of the patient
target Used by 5 transactions, one template, inherited 0 times
 
draft Street 0 … 1
epsos-dataelement-51
Id epsos-dataelement-51 (2013‑06‑04)
Cardinality 0 … 1

Description Name of street where the patient lives
Value Domain String
Example Oxford
target Used by 5 transactions, one template, inherited 0 times
 
draft Number of Street 0 … 1
epsos-dataelement-52
Id epsos-dataelement-52 (2013‑06‑04)
Cardinality 0 … 1

Description House number where the patient lives
Value Domain String
Example 221
target Used by 5 transactions, one template, inherited 0 times
 
draft City 0 … 1
epsos-dataelement-55
Id epsos-dataelement-55 (2013‑06‑04)
Cardinality 0 … 1

Description City where the patient lives
Value Domain String
Example London
target Used by 5 transactions, one template, inherited 0 times
 
draft Postal Code 0 … 1
epsos-dataelement-53
Id epsos-dataelement-53 (2013‑06‑04)
Cardinality 0 … 1

Description Postal code where the patient lives
Value Domain String
Example W1W 8LG
target Used by 5 transactions, one template, inherited 0 times
 
draft State or Province 0 … 1
epsos-dataelement-56
Id epsos-dataelement-56 (2013‑06‑04)
Cardinality 0 … 1

Description State or province where the patient lives
Value Domain String
Example London
target Used by 5 transactions, one template, inherited 0 times
 
draft Country 0 … 1
epsos-dataelement-54
Id epsos-dataelement-54 (2013‑06‑04)
Cardinality 0 … 1

Description Country where the patient lives
Value Domain String
Example UK
target Used by 5 transactions, one template, inherited 0 times
 
folder draft Telecom 1 … * Required
epsos-dataelement-300
Id epsos-dataelement-300 (2013‑11‑27 16:52:13)
Cardinality 1 … * Required

Description Telecommunication addresses of the patient
target Used by 5 transactions, one template, inherited 0 times
 
draft Telephone No 0 … *
epsos-dataelement-28
Id epsos-dataelement-28 (2013‑06‑03)
Cardinality 0 … *

Description Telephone number of the patient
Value Domain String
Example +45 20 7025 6161
target Used by 5 transactions, one template, inherited 0 times
 
draft Email 0 … *
epsos-dataelement-29
Id epsos-dataelement-29 (2013‑06‑03)
Cardinality 0 … *

Description Email address of the patient
Value Domain String
Example jens@hotmail.com
target Used by 5 transactions, one template, inherited 0 times
 
folder draft Preferred HP to contact 0 … 1
epsos-dataelement-30
Id epsos-dataelement-30 (2013‑06‑03)
Cardinality 0 … 1

Description Preferred Health Professional to contact. A foreign HP may need a contact (HP/legal organization) who knows the patient
target Used by 5 transactions, one template, inherited 0 times
 
folder draft Full Name 0 … 1
epsos-dataelement-46
Id epsos-dataelement-46 (2013‑06‑03)
Cardinality 0 … 1

Description Name of the HP/name of the legal organization. If it is an HP, the structure of the name will be the same as described in ‘Full name’ (Given name, family name/surname)
target Used by 5 transactions, one template, inherited 0 times
 
draft Given Name 0 … 1
epsos-dataelement-47
Id epsos-dataelement-47 (2013‑06‑03)
Cardinality 0 … 1

Description The Name of the HP (Example: John). This field can contain more than one element
Value Domain String
Example John
target Used by 5 transactions, one template, inherited 0 times
 
draft Family Name/Surname 0 … 1
epsos-dataelement-48
Id epsos-dataelement-48 (2013‑06‑03)
Cardinality 0 … 1

Description This field can contain more than one element.
Value Domain String
Example Español Smith
target Used by 5 transactions, one template, inherited 0 times
 
draft Prefix 0 … 1
epsos-dataelement-265
Id epsos-dataelement-265 (2013‑11‑27 11:44:48)
Cardinality 0 … 1

Value Domain String
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Suffix 0 … 1
epsos-dataelement-266
Id epsos-dataelement-266 (2013‑11‑27 11:45:03)
Cardinality 0 … 1

Value Domain String
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Telephone No 0 … *
epsos-dataelement-41
Id epsos-dataelement-41 (2013‑06‑03)
Cardinality 0 … *

Description Telephone number of the HP/name of the legal organization
Value Domain String
Example +45 20 7025 6161
target Used by 5 transactions, one template, inherited 0 times
 
draft Email 0 … *
epsos-dataelement-43
Id epsos-dataelement-43 (2013‑06‑03)
Cardinality 0 … *

Description Email address of the HP/name of the legal organization
Value Domain String
target Used by 5 transactions, one template, inherited 0 times
 
folder draft Legal Organization to contact 0 … 1
epsos-dataelement-31
Id epsos-dataelement-31 (2013‑06‑03)
Cardinality 0 … 1

Description Legal organization to contact about patient. A foreign HP may need a contact (HP/legal organization) who knows the patient
target Used by one transaction, one template, inherited 0 times
 
draft Organization Name 0 … 1
epsos-dataelement-33
Id epsos-dataelement-33 (2013‑06‑03)
Cardinality 0 … 1

Description Name of the organization
Value Domain String
target Used by one transaction, one template, inherited 0 times
 
draft Telephone No 0 … *
epsos-dataelement-49
Id epsos-dataelement-49 (2013‑06‑03)
Cardinality 0 … *

Description Telephone number of the organization
Value Domain String
Example +45 20 7025 6161
target Used by one transaction, one template, inherited 0 times
 
draft Email 0 … *
epsos-dataelement-50
Id epsos-dataelement-50 (2013‑06‑03)
Cardinality 0 … *

Description Email address of the organization
Value Domain String
target Used by one transaction, one template, inherited 0 times
 
folder draft Contact Person/legal guardian 0 … *
epsos-dataelement-34
Id epsos-dataelement-34 (2013‑06‑03)
Cardinality 0 … *

Description Contact or guardian of the patient
target Used by 2 transactions, 2 templates, inherited 0 times
 
draft Role of that person 0 … 1
epsos-dataelement-35
Id epsos-dataelement-35 (2013‑06‑03)
Cardinality 0 … 1

Description The role of the person: contact person or legal guardian
Value Domain Code
Choice list
Concept List
Concept Synonyms Description Assigned references
Contact Person
code "CON" (Contact) from code system "RoleClass"
code "ECON" (Emergency contact) from code system "RoleClass"
Legal Guardian
code "GUARD" (Legal guardian) from code system "RoleClass"
target Used by 2 transactions, one template, inherited 0 times
 
folder draft Full Name 0 … 1
epsos-dataelement-36
Id epsos-dataelement-36 (2013‑06‑03)
Cardinality 0 … 1

Description Full name of the contact person or guardian
target Used by 2 transactions, one template, inherited 0 times
 
draft Given Name 0 … 1
epsos-dataelement-37
Id epsos-dataelement-37 (2013‑06‑03)
Cardinality 0 … 1

Description The Name of the person (Example: John). This field can contain more than one element
Value Domain String
Example John
target Used by 2 transactions, 2 templates, inherited 0 times
 
draft Family Name/Surname 0 … 1
epsos-dataelement-38
Id epsos-dataelement-38 (2013‑06‑03)
Cardinality 0 … 1

Description This field can contain more than one element.
Value Domain String
Example Español Smith
target Used by 2 transactions, 2 templates, inherited 0 times
 
draft Prefix 0 … 1
epsos-dataelement-267
Id epsos-dataelement-267 (2013‑11‑27 11:45:27)
Cardinality 0 … 1

Value Domain String
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Suffix 0 … 1
epsos-dataelement-268
Id epsos-dataelement-268 (2013‑11‑27 11:45:39)
Cardinality 0 … 1

Value Domain String
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Telephone No 0 … *
epsos-dataelement-39
Id epsos-dataelement-39 (2013‑06‑03)
Cardinality 0 … *

Description Telephone number of the person
Value Domain String
Example +45 20 7025 6161
target Used by 2 transactions, 2 templates, inherited 0 times
 
draft Email 0 … *
epsos-dataelement-40
Id epsos-dataelement-40 (2013‑06‑03)
Cardinality 0 … *

Description Email address of the person
Value Domain String
target Used by 2 transactions, one template, inherited 0 times
 
folder draft Insurance Information 0 … 1
epsos-dataelement-14
Id epsos-dataelement-14 (2013‑05‑31)
Cardinality 0 … 1

Description Information about the insurance of the patient
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Insurance Number 0 … 1
epsos-dataelement-15
Id epsos-dataelement-15 (2013‑05‑31)
Cardinality 0 … 1

Description European Health Insurance Code (EHIC) number of the patient
Value Domain Identifier
Example QQ 12 34 56 A
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft Clinical Data 0 … *
epsos-dataelement-16
Id epsos-dataelement-16 (2013‑05‑30)
Cardinality 0 … *

Description Clinical information of the patient
target Used by 6 transactions, one template, inherited 0 times
 
folder draft Alerts 0 … *
epsos-dataelement-197
Id epsos-dataelement-197 (2013‑10‑24 11:47:59)
Cardinality 0 … *

target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Allergy 0 … *
epsos-dataelement-204
Id epsos-dataelement-204 (2013‑10‑24 11:49:17)
Cardinality 0 … *

Concept inherits from epsos-dataelement-58 (2013‑05‑31)
Description Allergies and intolerances
target Used by one transaction, 0 templates, inherited 0 times
 
draft Allergy description 0 … 1
epsos-dataelement-205
Id epsos-dataelement-205 (2013‑10‑24 11:49:34)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-68 (2013‑05‑31)
Description Description of the clinical manifestation of the allergy reaction. Example: Anaphylactic shock, angioedema (the clinical manifestation also gives information about the severity of the observed reaction)
Value Domain String
target Used by one transaction, 0 templates, inherited 0 times
 
draft Allergy code 0 … 1
epsos-dataelement-206
Id epsos-dataelement-206 (2013‑10‑24 11:49:34)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-69 (2013‑05‑31)
Description The code of the allergy
Value Domain Code
Choice list
Concept List

Value Set epSOSReactionAllergy (version DYNAMIC)

Value Set epSOSAdverseEventType (version DYNAMIC)
target Used by one transaction, 0 templates, inherited 0 times
 
draft Onset Date 0 … 1
epsos-dataelement-207
Id epsos-dataelement-207 (2013‑10‑24 11:49:34)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-70 (2013‑05‑31)
Description Date when the allergy started
Value Domain Date
Property
Timestamp precision
at least day, month and year
target Used by one transaction, 0 templates, inherited 0 times
 
draft Agent description 0 … 1
epsos-dataelement-208
Id epsos-dataelement-208 (2013‑10‑24 11:49:34)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-71 (2013‑05‑31)
Description Describes the agent (drug, food, chemical agent, etc) that is responsible for the adverse reaction
Value Domain String
target Used by one transaction, 0 templates, inherited 0 times
 
draft Agent Code 0 … 1
epsos-dataelement-209
Id epsos-dataelement-209 (2013‑10‑24 11:49:34)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-72 (2013‑05‑31)
Description The code of the allergen agent
Value Domain Code
Choice list
Concept List

Value Set epSOSAllergenNoDrugs (version DYNAMIC)

Value Set epSOSWHO-ATC (version DYNAMIC)
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Medical Alert Information 0 … *
epsos-dataelement-214
Id epsos-dataelement-214 (2013‑10‑24 14:15:28)
Cardinality 0 … *

Description Other alerts not included in allergies
Comment

The field “alerts” was originally defined to include all the important and objective medical information that should be highlighted (such as allergies, thrombosis risk, immune deficit …etc). When defining the content only allergies and intolerance to drugs appear to be the common understanding and the easiest to be transferred.

A lot of surveys are being made in different countries (not only in Europe) to make a more evidence-based definition of what should represented and should not byt  the concept “alerts”, hence not enough information could be provided to take a further decision.  As epSOS’s intention was not to duplicate information, this shall not be repeated.  Alerts are diffucult to represent since they are contextual.  Alerts may be represented as severe or life-threatening allergies or other adverse reactions. Another area are certain selected procedures and implanted devivces.  The section Allergies and Other Adverse Reactions contains the medical alerts as well, based on the serverity, and their representation becomes a Country B choice.

target Used by one transaction, 0 templates, inherited 0 times
 
draft Health Care Alert code 0 … 1
epsos-dataelement-216
Id epsos-dataelement-216 (2013‑10‑24 14:19:45)
Cardinality 0 … 1

Description The code of the health care alert
Value Domain Code
target Used by one transaction, 0 templates, inherited 0 times
 
draft Health Care Alert description 0 … 1
epsos-dataelement-215
Id epsos-dataelement-215 (2013‑10‑24 14:17:25)
Cardinality 0 … 1

Description Medical Alert Information: any other clinical information that is imperative to know so that the life or health of the patient does not come under threat
Value Domain String
Example intolerance to aspirin due to gastrointestinal bleeding
Example intolerance to captopril because of cough (the patient is not allergic to captopril but can´t tolerate it because of persistent cough
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft History of Past Illness 0 … *
epsos-dataelement-192
Id epsos-dataelement-192 (2013‑10‑24 11:30:02)
Cardinality 0 … *

target Used by one transaction, one template, inherited 0 times
 
folder draft Problem/Diagnosis 0 … *
epsos-dataelement-222
Id epsos-dataelement-222 (2013‑10‑24 14:22:16)
Cardinality 0 … *

Concept inherits from epsos-dataelement-83 (2013‑05‑31)
Comment
target Used by one transaction, one template, inherited 0 times
 
draft Problem/diagnosis Description 0 … 1
epsos-dataelement-223
Id epsos-dataelement-223 (2013‑10‑24 14:23:02)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-84 (2013‑05‑31)
Description Problems or diagnosis not included under the definition of ‘Current problems or diagnosis’. Example: hepatic cyst (the patient has been treated with an hepatic cystectomy that solved the problem and therefore it ́s a closed problem)
Value Domain String
target Used by one transaction, one template, inherited 0 times
 
draft Problem/diagnosis Id (Code) 0 … 1
epsos-dataelement-224
Id epsos-dataelement-224 (2013‑10‑24 14:23:02)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-85 (2013‑05‑31)
Description Normalized identifier
Value Domain Code
Choice list
Concept List

Value Set epSOSIllnessesandDisorders (version DYNAMIC)
target Used by one transaction, one template, inherited 0 times
 
draft Problem Status 0 … 1
epsos-dataelement-306
Id epsos-dataelement-306 (2013‑10‑24 14:23:02)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-305 (2013‑11‑28 16:40:53)
Value Domain Code
Choice list
Concept List

Value Set epSOSStatusCode (version DYNAMIC)
target Used by one transaction, one template, inherited 0 times
 
draft Problem Severity 0 … 1
epsos-dataelement-302
Id epsos-dataelement-302 (2013‑10‑24 14:23:02)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-301 (2013‑11‑28)
Value Domain Code
Choice list
Concept List

Value Set epSOSSeverity (version DYNAMIC)
target Used by one transaction, one template, inherited 0 times
 
draft Onset Time 0 … 1
epsos-dataelement-225
Id epsos-dataelement-225 (2013‑10‑24 14:23:02)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-86 (2013‑05‑31)
Description Date of problem onset
Value Domain Date
target Used by one transaction, one template, inherited 0 times
 
draft End date 0 … 1
epsos-dataelement-226
Id epsos-dataelement-226 (2013‑10‑24 14:23:02)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-174 (2013‑10‑16 14:07:46)
Description Problem resolution date
Value Domain Date
Property
Timestamp precision
at least day, month and year
target Used by one transaction, one template, inherited 0 times
 
draft Resolution Circumstances 0 … 1
epsos-dataelement-227
Id epsos-dataelement-227 (2013‑10‑24 14:23:02)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-175 (2013‑10‑16 14:09:33)
Description Describes the reason by which the problem changed the status from current to inactive (e.g. surgical procedure, medical treatment, etc). This field includes ‘free text’ if the resolution circumstances are not already included in other fields. Example: It can happen that this field is already included in other like Surgical Procedure, medical device etc, eg: hepatic cystectomy (this wil be the ‘Resolution Circumstances’ for the problem ‘hepatic cyst’ and will be included in surgical procedures)
Value Domain String
target Used by one transaction, one template, inherited 0 times
 
folder draft Vaccination 0 … *
epsos-dataelement-217
Id epsos-dataelement-217 (2013‑10‑24 14:21:37)
Cardinality 0 … *

Concept inherits from epsos-dataelement-167 (2013‑09‑27)
target Used by one transaction, 0 templates, inherited 0 times
 
draft Vaccine brand name 0 … 1
epsos-dataelement-218
Id epsos-dataelement-218 (2013‑10‑24 14:22:00)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-168 (2013‑09‑27 11:27:51)
Description Brand name of the vaccination
Value Domain String
target Used by one transaction, 0 templates, inherited 0 times
 
draft Vaccine description 0 … 1
epsos-dataelement-219
Id epsos-dataelement-219 (2013‑10‑24 14:22:00)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-171 (2013‑09‑27 11:29:50)
Description Description of the vaccine
Value Domain String
target Used by one transaction, 0 templates, inherited 0 times
 
draft Vaccine code 0 … 1
epsos-dataelement-220
Id epsos-dataelement-220 (2013‑10‑24 14:22:00)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-170 (2013‑09‑27 11:29:18)
Description The code of the vaccine
Value Domain Code
Choice list
Concept List

Value Set epSOSVaccine (version DYNAMIC)
target Used by one transaction, 0 templates, inherited 0 times
 
draft Vaccination date 0 … 1
epsos-dataelement-221
Id epsos-dataelement-221 (2013‑10‑24 14:22:00)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-169 (2013‑09‑27 11:28:23)
Description The date the vaccination was done
Value Domain Date
Property
Timestamp precision
at least day, month and year
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Surgical Procedure 0 … *
epsos-dataelement-210
Id epsos-dataelement-210 (2013‑10‑24 13:42:06)
Cardinality 0 … *

Concept inherits from epsos-dataelement-1 (2013‑05‑31)
target Used by one transaction, 0 templates, inherited 0 times
 
draft Procedure description 0 … 1
epsos-dataelement-211
Id epsos-dataelement-211 (2013‑10‑24 13:42:21)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-3 (2013‑05‑31)
Description Describes the type of procedure that has been executed as part of the healthcare event.
Value Domain String
Example Colonoscopy
target Used by one transaction, 0 templates, inherited 0 times
 
draft Procedure Id (code) 0 … 1
epsos-dataelement-212
Id epsos-dataelement-212 (2013‑10‑24 13:42:21)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-2 (2013‑05‑31)
Description Normalized identifier
Value Domain Code
Choice list
Concept List

Value Set epSOSProcedures (version DYNAMIC)
Example 73761001
target Used by one transaction, 0 templates, inherited 0 times
 
draft Procedure Date 0 … 1
epsos-dataelement-213
Id epsos-dataelement-213 (2013‑10‑24 13:42:21)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-4 (2013‑05‑31)
Description Date when procedure was performed
Value Domain Date+time
Property
Timestamp precision
at least day, month and year
Example 02/14/2013
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Medical Problems 0 … *
epsos-dataelement-82
Id epsos-dataelement-82 (2013‑05‑31)
Cardinality 0 … *

target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Problem/Diagnosis 0 … *
epsos-dataelement-228
Id epsos-dataelement-228 (2013‑10‑24 14:26:14)
Cardinality 0 … *

Concept inherits from epsos-dataelement-83 (2013‑05‑31)
Comment
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Problem/diagnosis Description 0 … 1
epsos-dataelement-229
Id epsos-dataelement-229 (2013‑10‑24 14:26:31)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-84 (2013‑05‑31)
Description Problems or diagnosis not included under the definition of ‘Current problems or diagnosis’. Example: hepatic cyst (the patient has been treated with an hepatic cystectomy that solved the problem and therefore it ́s a closed problem)
Value Domain String
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Problem/diagnosis Id (Code) 0 … 1
epsos-dataelement-230
Id epsos-dataelement-230 (2013‑10‑24 14:26:31)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-85 (2013‑05‑31)
Description Normalized identifier
Value Domain Code
Choice list
Concept List

Value Set epSOSIllnessesandDisorders (version DYNAMIC)
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Problem Status 0 … 1
epsos-dataelement-307
Id epsos-dataelement-307 (2013‑10‑24 14:23:02)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-305 (2013‑11‑28 16:40:53)
Value Domain Code
Choice list
Concept List

Value Set epSOSStatusCode (version DYNAMIC)
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Problem Severity 0 … 1
epsos-dataelement-303
Id epsos-dataelement-303 (2013‑10‑24 14:23:02)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-301 (2013‑11‑28)
Value Domain Code
Choice list
Concept List

Value Set epSOSSeverity (version DYNAMIC)
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Onset Time 0 … 1
epsos-dataelement-231
Id epsos-dataelement-231 (2013‑10‑24 14:26:31)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-86 (2013‑05‑31)
Description Date of problem onset
Value Domain Date
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft End date 0 … 1
epsos-dataelement-232
Id epsos-dataelement-232 (2013‑10‑24 14:26:31)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-174 (2013‑10‑16 14:07:46)
Description Problem resolution date
Value Domain Date
Property
Timestamp precision
at least day, month and year
target Used by one transaction, 0 templates, inherited 0 times
 
draft Resolution Circumstances 0 … 1
epsos-dataelement-233
Id epsos-dataelement-233 (2013‑10‑24 14:26:31)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-175 (2013‑10‑16 14:09:33)
Description Describes the reason by which the problem changed the status from current to inactive (e.g. surgical procedure, medical treatment, etc). This field includes ‘free text’ if the resolution circumstances are not already included in other fields. Example: It can happen that this field is already included in other like Surgical Procedure, medical device etc, eg: hepatic cystectomy (this wil be the ‘Resolution Circumstances’ for the problem ‘hepatic cyst’ and will be included in surgical procedures)
Value Domain String
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Surgical Procedure 0 … *
epsos-dataelement-188
Id epsos-dataelement-188 (2013‑10‑24 11:13:22)
Cardinality 0 … *

Concept inherits from epsos-dataelement-1 (2013‑05‑31)
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Procedure description 0 … 1
epsos-dataelement-189
Id epsos-dataelement-189 (2013‑10‑24 11:17:39)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-3 (2013‑05‑31)
Description Describes the type of procedure that has been executed as part of the healthcare event.
Value Domain String
Example Colonoscopy
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Procedure Id (code) 0 … 1
epsos-dataelement-190
Id epsos-dataelement-190 (2013‑10‑24 11:17:39)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-2 (2013‑05‑31)
Description Normalized identifier
Value Domain Code
Choice list
Concept List

Value Set epSOSProcedures (version DYNAMIC)
Example 73761001
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Procedure Date 0 … 1
epsos-dataelement-191
Id epsos-dataelement-191 (2013‑10‑24 11:17:39)
Cardinality 0 … 1

Concept inherits from epsos-dataelement-4 (2013‑05‑31)
Description Date when procedure was performed
Value Domain Date+time
Property
Timestamp precision
at least day, month and year
Example 02/14/2013
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft Medical Devices and Implants 0 … *
epsos-dataelement-87
Id epsos-dataelement-87 (2013‑05‑31)
Cardinality 0 … *

target Used by 2 transactions, one template, inherited 0 times
 
draft Medical Devices and Implants Description 0 … 1
epsos-dataelement-88
Id epsos-dataelement-88 (2013‑05‑31)
Cardinality 0 … 1

Description Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices as cardiac pacemakers, implantable defribillator, prothesis, feromagnetic bone implants etc that are important to be known by HP.
Value Domain String
target Used by 2 transactions, one template, inherited 0 times
 
draft Device Code 0 … 1
epsos-dataelement-89
Id epsos-dataelement-89 (2013‑05‑31)
Cardinality 0 … 1

Description Normalized identifier
Value Domain Code
Choice list
Concept List

Value Set epSOSMedicalDevices (version DYNAMIC)
target Used by 2 transactions, one template, inherited 0 times
 
draft Implant Date 0 … 1
epsos-dataelement-90
Id epsos-dataelement-90 (2013‑05‑31)
Cardinality 0 … 1

Value Domain Date
target Used by 2 transactions, one template, inherited 0 times
 
folder draft Treatments 0 … *
epsos-dataelement-128
Id epsos-dataelement-128 (2013‑09‑26 16:58:01)
Cardinality 0 … *

target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Treatment description 0 … 1
epsos-dataelement-129
Id epsos-dataelement-129 (2013‑09‑26 16:58:50)
Cardinality 0 … 1

Description Therapeutic treatment that does not include drugs (diet, physical excersize constraints etc)
Value Domain String
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Treatment code 0 … 1
epsos-dataelement-130
Id epsos-dataelement-130 (2013‑09‑26 17:00:20)
Cardinality 0 … 1

Description normalized identifier, concept code
Value Domain Code
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Onset time 0 … 1
epsos-dataelement-131
Id epsos-dataelement-131 (2013‑09‑26 17:01:28)
Cardinality 0 … 1

Description Date of treatment onset
Value Domain Date
Property
Timestamp precision
at least day, month and year
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft Care plan 0 … *
epsos-dataelement-95
Id epsos-dataelement-95 (2013‑05‑31)
Cardinality 0 … *

target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Recommendations Description 0 … 1
epsos-dataelement-96
Id epsos-dataelement-96 (2013‑05‑31)
Cardinality 0 … 1

Description Therapeutic recommendations that do not include drugs (diet, physical exercise constraints, etc.)
Value Domain String
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Recommendations Id (code) 0 … 1
epsos-dataelement-97
Id epsos-dataelement-97 (2013‑05‑31)
Cardinality 0 … 1

Description Normalized identifier
Value Domain Code
Choice list
Concept List

Value Set epSOSResolutionOutcome (version DYNAMIC)
Example 73761001
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft Disability or function 0 … *
epsos-dataelement-98
Id epsos-dataelement-98 (2013‑05‑31)
Cardinality 0 … *

notice There is an open issue with this item:
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Invalidity description 0 … 1
epsos-dataelement-99
Id epsos-dataelement-99 (2013‑05‑31)
Cardinality 0 … 1

Description Need of the patient to be continuously assisted by third parties. Invalidity status may influence decisions about how to administer treatments
Value Domain String
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Onset time 0 … 1
epsos-dataelement-132
Id epsos-dataelement-132 (2013‑09‑26 17:03:54)
Cardinality 0 … 1

Description Date of invalidity onset
Value Domain Date
Property
Timestamp precision
at least day, month and year
target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Medication 0 … 1
epsos-dataelement-101
Id epsos-dataelement-101 (2013‑05‑31)
Cardinality 0 … 1

target Used by 5 transactions, one template, inherited 0 times
 
folder draft Prescription 0 … *
epsos-dataelement-102
Id epsos-dataelement-102 (2013‑05‑31)
Cardinality 0 … *

target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Prescription identification 1 … 1 Mandatory
epsos-dataelement-134
Id epsos-dataelement-134 (2013‑09‑27 10:48:19)
Cardinality 1 … 1 Mandatory

Description Unique identification of the prescription
Value Domain Identifier
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Medicinal product code 0 … 1 Required
epsos-dataelement-135
Id epsos-dataelement-135 (2013‑09‑27 10:50:26)
Cardinality 0 … 1 Required

Description Code that identifies the medicinal product description
Value Domain Code
target Used by 4 transactions, one template, inherited 0 times
 
draft Date of issue of prescription 1 … 1 Mandatory
epsos-dataelement-136
Id epsos-dataelement-136 (2013‑09‑27 10:51:52)
Cardinality 1 … 1 Mandatory

Description Date when medicine has been prescribed
Value Domain Date
Property
Timestamp precision
at least day, month and year
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Brand name 1 … 1 Required
epsos-dataelement-137
Id epsos-dataelement-137 (2013‑09‑27 10:52:59)
Cardinality 1 … 1 Required

Description Original brand name of the medicine (in the language of the country in which the prescription was made)
Value Domain String
target Used by 4 transactions, one template, inherited once
 
draft Active ingredient 1 … * Required
epsos-dataelement-103
Id epsos-dataelement-103 (2013‑05‑31)
Cardinality 1 … * Required

Description Substance that alone or in combination with one or more other ingredients produces the intended activity of a medicinal product.
Value Domain String
Example Paracetamol
target Used by 4 transactions, one template, inherited once
 
draft Active ingredient code 1 … * Mandatory
epsos-dataelement-104
Id epsos-dataelement-104 (2013‑05‑31)
Cardinality 1 … * Mandatory

Description Code that identifies the Active ingredient
Value Domain Code
Choice list
Concept List

Value Set epSOSActiveIngredient (version DYNAMIC)
target Used by 4 transactions, one template, inherited once
 
draft Strength 1 … * Mandatory
epsos-dataelement-105
Id epsos-dataelement-105 (2013‑05‑31)
Cardinality 1 … * Mandatory

Description The content of the active ingredient expressed quantitatively per dosage unit, per unit of volume or per unit of weight, according to the pharmaceutical dose form. Example: 500 mg per tablet
Value Domain Quantity
Example 500 mg per tablet
target Used by 4 transactions, one template, inherited once
 
draft Medicinal product package size 1 … 1 Required
epsos-dataelement-138
Id epsos-dataelement-138 (2013‑09‑27 10:54:04)
Cardinality 1 … 1 Required

Description The size of the package prescribed
Value Domain Count
target Used by 4 transactions, one template, inherited once
 
draft Pharmaceutical dose form 1 … 1 Mandatory
epsos-dataelement-106
Id epsos-dataelement-106 (2013‑05‑31)
Cardinality 1 … 1 Mandatory

Description It is the form in which a pharmaceutical product is presented in the medicinal product package (e.g. tablets, syrup)
Value Domain Code
Choice list
Concept List

Value Set epSOSDoseForm (version DYNAMIC)
Example tablets
Example syrup
target Used by 4 transactions, one template, inherited once
 
draft Number of packages 1 … 1 Required
epsos-dataelement-139
Id epsos-dataelement-139 (2013‑09‑27 11:00:57)
Cardinality 1 … 1 Required

Description Number of boxes that have been prescribed
Value Domain Quantity
target Used by 4 transactions, 0 templates, inherited once
 
draft Number of units per intake 1 … 1 Required
epsos-dataelement-107
Id epsos-dataelement-107 (2013‑05‑31)
Cardinality 1 … 1 Required

Description The number of units per intake that the patient is taking (e.g. 1 tablet)
Comment Posology has been defined from the functional point of view as containing these three components: number of units per intake, frequency of intakes and duration of treatment:(example: 1 unit/intake every 24 hours for a duration of 14 days.

There has to be space for posology in free text with the possibility of a null flavor
Value Domain Quantity
Example 1 tablet
target Used by 4 transactions, one template, inherited once
 
draft Frequency of intakes 1 … * Required
epsos-dataelement-108
Id epsos-dataelement-108 (2013‑05‑31)
Cardinality 1 … * Required

Description Frequency of intakes (per hours/day/month/ week..). Example: each 24 hours
Comment There has to be space for posology in free text with the possibility of a null flavor
Value Domain Quantity
Example each 24 hours
target Used by 4 transactions, one template, inherited once
 
draft Duration of treatment 1 … 1 Required
epsos-dataelement-109
Id epsos-dataelement-109 (2013‑05‑31)
Cardinality 1 … 1 Required

Comment There has to be space for posology in free text with the possibility of a null flavor
Value Domain Quantity
Example during 14 days
target Used by 4 transactions, one template, inherited 0 times
 
draft Date of onset of treatment 1 … 1 Required
epsos-dataelement-110
Id epsos-dataelement-110 (2013‑05‑31)
Cardinality 1 … 1 Required

Description Date when patient needs to start taking the medicine prescribed
Value Domain Date+time
target Used by 4 transactions, one template, inherited 0 times
 
draft Route of administration 0 … 1 Required
epsos-dataelement-140
Id epsos-dataelement-140 (2013‑09‑27 11:05:39)
Cardinality 0 … 1 Required

Description

Indicates the part of the body through or into which, or the way in which, the medicinal product is intended to be introduced. In some cases a medicinal product can be intended for more than one route and/or method of administration.

NOTE FOR GUIDANCE ON DATA ELEMENTS AND STANDARDS FOR DRUG DICTIONARIES

(EMEA/CHMP/ICH/168535/2005)

Value Domain Code
Choice list
Concept List

Value Set epSOSRouteofAdministration (version DYNAMIC)
target Used by 4 transactions, one template, inherited once
 
draft Instructions to patient 0 … 1 Required
epsos-dataelement-141
Id epsos-dataelement-141 (2013‑09‑27 11:06:50)
Cardinality 0 … 1 Required

Description The prescriber might give to the patient instructions; They must be presented in the original language.
Value Domain Text
target Used by 4 transactions, one template, inherited 0 times
 
draft Advice to dispenser 0 … 1
epsos-dataelement-142
Id epsos-dataelement-142 (2013‑09‑27 11:07:18)
Cardinality 0 … 1

Description The prescriber might give instructions to the dispenser. The information will be in the original language as automatic translation is not secure enough. To avoid legal and ethical issues to the dispenser, it should be wise to implement an option that allows the dispenser to decide, knowing that this data is available, whether he wants to consult it or not.
Value Domain String
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Prescriber 0 … 1
epsos-dataelement-236
Id epsos-dataelement-236 (2013‑11‑27 11:02:18)
Cardinality 0 … 1

target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Prescriber Profession 0 … 1
epsos-dataelement-237
Id epsos-dataelement-237 (2013‑11‑27 11:03:07)
Cardinality 0 … 1

Value Domain Code
Choice list
Concept List

Value Set epSOSHealthcareProfessionalRoles (version DYNAMIC)
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Prescriber Speciality 0 … 1
epsos-dataelement-238
Id epsos-dataelement-238 (2013‑11‑27 11:03:56)
Cardinality 0 … 1

Description Some countries need the specialty of the prescriber for the epSOS ePrescription to be seen as valid. In the epSOS phase 1 ePrescription data set, this element is not basic (minimum), therefore not always filled in. The proposal is to define the specialty of the prescriber as a basic element, so it should be filled in, if available. As it could be that this information is not available in every country, null values should be allowed.
Value Domain Code
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Timestamp of Prescribing 0 … 1
epsos-dataelement-239
Id epsos-dataelement-239 (2013‑11‑27 11:04:21)
Cardinality 0 … 1

Description Date/time the medication was prescribed
Value Domain Date+time
Property
Timestamp precision
at least day, month and year
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Prescriber Identification 0 … 1
epsos-dataelement-240
Id epsos-dataelement-240 (2013‑11‑27 11:04:55)
Cardinality 0 … 1

Description Unique identification of the prescriber
Value Domain Identifier
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Prescriber Full Name 0 … 1
epsos-dataelement-241
Id epsos-dataelement-241 (2013‑11‑27 11:05:18)
Cardinality 0 … 1

Description The full name of the Health Professional
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Given Name 0 … 1
epsos-dataelement-242
Id epsos-dataelement-242 (2013‑11‑27 11:05:49)
Cardinality 0 … 1

Description The Name of the Prescriber (Example: John). This field can contain more than one element
Value Domain String
Example John
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Family Name/Surname 0 … 1
epsos-dataelement-243
Id epsos-dataelement-243 (2013‑11‑27 11:06:25)
Cardinality 0 … 1

Description This field can contain more than one element.
Value Domain String
Example Español Smith
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Prefix 0 … 1
epsos-dataelement-269
Id epsos-dataelement-269 (2013‑11‑27 11:45:59)
Cardinality 0 … 1

Value Domain String
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Suffix 0 … 1
epsos-dataelement-270
Id epsos-dataelement-270 (2013‑11‑27 11:46:17)
Cardinality 0 … 1

Value Domain String
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Prescriber Telecom 0 … *
epsos-dataelement-282
Id epsos-dataelement-282 (2013‑11‑27 12:27:48)
Cardinality 0 … *

target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Telephone No 0 … 1
epsos-dataelement-280
Id epsos-dataelement-280 (2013‑11‑27 12:27:03)
Cardinality 0 … 1

Value Domain String
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Email 0 … 1
epsos-dataelement-281
Id epsos-dataelement-281 (2013‑11‑27 12:27:19)
Cardinality 0 … 1

Value Domain String
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Prescriber Healthcare Facility 0 … 1
epsos-dataelement-244
Id epsos-dataelement-244 (2013‑11‑27 11:09:08)
Cardinality 0 … 1

Description Information about the healthcare facility where the health professional works
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Identifier 0 … 1
epsos-dataelement-245
Id epsos-dataelement-245 (2013‑11‑27 11:09:42)
Cardinality 0 … 1

Description Unique identification of the healthcare facility
Value Domain Identifier
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
epsos-dataelement-246
Id epsos-dataelement-246 (2013‑11‑27 11:09:57)
Cardinality 0 … 1

Description Name of the healthcare facility
Value Domain String
Example St. Johns Hospital
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Healthcare Facility Telecom 0 … *
epsos-dataelement-283
Id epsos-dataelement-283 (2013‑11‑27 12:28:21)
Cardinality 0 … *

target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Telephone No 0 … 1
epsos-dataelement-278
Id epsos-dataelement-278 (2013‑11‑27 12:24:25)
Cardinality 0 … 1

Value Domain String
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Email 0 … 1
epsos-dataelement-279
Id epsos-dataelement-279 (2013‑11‑27 12:24:51)
Cardinality 0 … 1

Value Domain String
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Prescriber Credentialing Organization 0 … *
epsos-dataelement-290
Id epsos-dataelement-290 (2013‑11‑27 13:38:39)
Cardinality 0 … *

Description The organization which provided the credentialing for the prescriber
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Identifier 0 … 1
epsos-dataelement-291
Id epsos-dataelement-291 (2013‑11‑27 13:39:16)
Cardinality 0 … 1

Description Unique identification of the organization which provided the credentialing for the prescriber
Value Domain Identifier
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
epsos-dataelement-292
Id epsos-dataelement-292 (2013‑11‑27 13:39:55)
Cardinality 0 … 1

Description The name of the organization which provided the credentialing for the prescriber
Value Domain String
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Surgical Procedure 0 … *
epsos-dataelement-1
Id epsos-dataelement-1 (2013‑05‑31)
Cardinality 0 … *

target Used by one transaction, one template, inherited 2 times
 
draft Procedure description 0 … 1
epsos-dataelement-3
Id epsos-dataelement-3 (2013‑05‑31)
Cardinality 0 … 1

Description Describes the type of procedure that has been executed as part of the healthcare event.
Value Domain String
Example Colonoscopy
target Used by one transaction, one template, inherited 2 times
 
draft Procedure Id (code) 0 … 1
epsos-dataelement-2
Id epsos-dataelement-2 (2013‑05‑31)
Cardinality 0 … 1

Description Normalized identifier
Value Domain Code
Choice list
Concept List

Value Set epSOSProcedures (version DYNAMIC)
Example 73761001
target Used by one transaction, one template, inherited 2 times
 
draft Procedure Date 0 … 1
epsos-dataelement-4
Id epsos-dataelement-4 (2013‑05‑31)
Cardinality 0 … 1

Description Date when procedure was performed
Value Domain Date+time
Property
Timestamp precision
at least day, month and year
Example 02/14/2013
target Used by one transaction, one template, inherited 2 times
 
folder draft Problem/Diagnosis 0 … *
epsos-dataelement-83
Id epsos-dataelement-83 (2013‑05‑31)
Cardinality 0 … *

Comment
target Used by one transaction, one template, inherited 2 times
 
draft Problem/diagnosis Description 0 … 1
epsos-dataelement-84
Id epsos-dataelement-84 (2013‑05‑31)
Cardinality 0 … 1

Description Problems or diagnosis not included under the definition of ‘Current problems or diagnosis’. Example: hepatic cyst (the patient has been treated with an hepatic cystectomy that solved the problem and therefore it ́s a closed problem)
Value Domain String
target Used by one transaction, one template, inherited 2 times
 
draft Problem/diagnosis Id (Code) 0 … 1
epsos-dataelement-85
Id epsos-dataelement-85 (2013‑05‑31)
Cardinality 0 … 1

Description Normalized identifier
Value Domain Code
Choice list
Concept List

Value Set epSOSIllnessesandDisorders (version DYNAMIC)
target Used by one transaction, one template, inherited 2 times
 
draft Problem Status 0 … 1
epsos-dataelement-305
Id epsos-dataelement-305 (2013‑11‑28 16:40:53)
Cardinality 0 … 1

Value Domain Code
Choice list
Concept List

Value Set epSOSStatusCode (version DYNAMIC)
target Used by one transaction, one template, inherited 2 times
 
draft Problem Severity 0 … 1
epsos-dataelement-301
Id epsos-dataelement-301 (2013‑11‑28)
Cardinality 0 … 1

Value Domain Code
Choice list
Concept List

Value Set epSOSSeverity (version DYNAMIC)
target Used by one transaction, one template, inherited 2 times
 
draft Onset Time 0 … 1
epsos-dataelement-86
Id epsos-dataelement-86 (2013‑05‑31)
Cardinality 0 … 1

Description Date of problem onset
Value Domain Date
target Used by one transaction, 2 templates, inherited 2 times
 
draft End date 0 … 1
epsos-dataelement-174
Id epsos-dataelement-174 (2013‑10‑16 14:07:46)
Cardinality 0 … 1

Description Problem resolution date
Value Domain Date
Property
Timestamp precision
at least day, month and year
target Used by one transaction, 2 templates, inherited 2 times
 
draft Resolution Circumstances 0 … 1
epsos-dataelement-175
Id epsos-dataelement-175 (2013‑10‑16 14:09:33)
Cardinality 0 … 1

Description Describes the reason by which the problem changed the status from current to inactive (e.g. surgical procedure, medical treatment, etc). This field includes ‘free text’ if the resolution circumstances are not already included in other fields. Example: It can happen that this field is already included in other like Surgical Procedure, medical device etc, eg: hepatic cystectomy (this wil be the ‘Resolution Circumstances’ for the problem ‘hepatic cyst’ and will be included in surgical procedures)
Value Domain String
target Used by one transaction, one template, inherited 2 times
 
folder draft Physical Findings 0 … *
epsos-dataelement-117
Id epsos-dataelement-117 (2013‑05‑31)
Cardinality 0 … *

target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Vital Signs Observations 0 … *
epsos-dataelement-118
Id epsos-dataelement-118 (2013‑05‑31)
Cardinality 0 … *

target Used by 3 transactions, one template, inherited 0 times
 
folder draft Blood Pressure 0 … *
epsos-dataelement-119
Id epsos-dataelement-119 (2013‑05‑31)
Cardinality 0 … *

Description One value of blood pressure which includes: systolic Blood Pressure and Diastolic Blood pressure
target Used by 3 transactions, one template, inherited 0 times
 
draft Systolic Blood Pressure 0 … 1
epsos-dataelement-120
Id epsos-dataelement-120 (2013‑05‑31)
Cardinality 0 … 1

Terminology Asscociation This concept is represented by code "8480-6" (INTRAVASCULAR SYSTOLIC) from code system 2.16.840.1.113883.6.1 LOINC
Value Domain Quantity
Property
min include max include unit min. fraction digits default fixed
min include max include        
mm[Hg]  
target Used by 3 transactions, one template, inherited 0 times
 
draft Diastolic Blood Pressure 0 … 1
epsos-dataelement-121
Id epsos-dataelement-121 (2013‑05‑31)
Cardinality 0 … 1

Terminology Asscociation This concept is represented by code "8462-4" (INTRAVASCULAR DIASTOLIC) from code system 2.16.840.1.113883.6.1 LOINC
Value Domain Quantity
Property
min include max include unit min. fraction digits default fixed
min include max include        
mm[Hg]  
target Used by 3 transactions, one template, inherited 0 times
 
draft Date when blood pressure was measured 0 … 1
epsos-dataelement-122
Id epsos-dataelement-122 (2013‑05‑31)
Cardinality 0 … 1

Description Date when blood pressure was measured
Value Domain Date
Example 01/01/2010
target Used by 3 transactions, one template, inherited 0 times
 
folder draft Diagnostic Tests 0 … *
epsos-dataelement-123
Id epsos-dataelement-123 (2013‑05‑31)
Cardinality 0 … *

target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Blood Group 0 … 1
epsos-dataelement-124
Id epsos-dataelement-124 (2013‑05‑31)
Cardinality 0 … 1

target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Result of Blood Group 0 … 1
epsos-dataelement-125
Id epsos-dataelement-125 (2013‑05‑31)
Cardinality 0 … 1

Description Result from the blood group test made to the patient
Value Domain Code
Choice list
Concept List

Value Set epSOSBloodGroup (version DYNAMIC)
Example blood group A
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
epsos-dataelement-126
Id epsos-dataelement-126 (2013‑05‑31)
Cardinality 0 … 1

Description Date in which the blood group test was done. This field may contain only the year if day and month are not available. Eg: 01/01/2009
Value Domain Date
Property
Timestamp precision
day, month and year
Example 01/01/2009
target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Vaccination 0 … *
epsos-dataelement-167
Id epsos-dataelement-167 (2013‑09‑27)
Cardinality 0 … *

target Used by 3 transactions, one template, inherited once
 
draft Vaccine brand name 0 … 1
epsos-dataelement-168
Id epsos-dataelement-168 (2013‑09‑27 11:27:51)
Cardinality 0 … 1

Description Brand name of the vaccination
Value Domain String
target Used by 3 transactions, one template, inherited once
 
draft Vaccine description 0 … 1
epsos-dataelement-171
Id epsos-dataelement-171 (2013‑09‑27 11:29:50)
Cardinality 0 … 1

Description Description of the vaccine
Value Domain String
target Used by 3 transactions, one template, inherited once
 
draft Vaccine code 0 … 1
epsos-dataelement-170
Id epsos-dataelement-170 (2013‑09‑27 11:29:18)
Cardinality 0 … 1

Description The code of the vaccine
Value Domain Code
Choice list
Concept List

Value Set epSOSVaccine (version DYNAMIC)
target Used by 3 transactions, one template, inherited once
 
draft Vaccination date 0 … 1
epsos-dataelement-169
Id epsos-dataelement-169 (2013‑09‑27 11:28:23)
Cardinality 0 … 1

Description The date the vaccination was done
Value Domain Date
Property
Timestamp precision
at least day, month and year
target Used by 3 transactions, one template, inherited once
 
folder draft Allergy 0 … *
epsos-dataelement-58
Id epsos-dataelement-58 (2013‑05‑31)
Cardinality 0 … *

Description Allergies and intolerances
target Used by 3 transactions, one template, inherited once
 
draft Allergy description 0 … 1
epsos-dataelement-68
Id epsos-dataelement-68 (2013‑05‑31)
Cardinality 0 … 1

Description Description of the clinical manifestation of the allergy reaction. Example: Anaphylactic shock, angioedema (the clinical manifestation also gives information about the severity of the observed reaction)
Value Domain String
target Used by 3 transactions, one template, inherited once
 
draft Allergy code 0 … 1
epsos-dataelement-69
Id epsos-dataelement-69 (2013‑05‑31)
Cardinality 0 … 1

Description The code of the allergy
Value Domain Code
Choice list
Concept List

Value Set epSOSReactionAllergy (version DYNAMIC)

Value Set epSOSAdverseEventType (version DYNAMIC)
target Used by 3 transactions, one template, inherited once
 
draft Allergy Severity 0 … 1
epsos-dataelement-304
Id epsos-dataelement-304 (2013‑05‑31)
Cardinality 0 … 1

Value Domain Code
Choice list
Concept List

Value Set epSOSSeverity (version DYNAMIC)
target Used by 3 transactions, one template, inherited 0 times
 
draft Onset Date 0 … 1
epsos-dataelement-70
Id epsos-dataelement-70 (2013‑05‑31)
Cardinality 0 … 1

Description Date when the allergy started
Value Domain Date
Property
Timestamp precision
at least day, month and year
target Used by 3 transactions, one template, inherited once
 
draft Agent description 0 … 1
epsos-dataelement-71
Id epsos-dataelement-71 (2013‑05‑31)
Cardinality 0 … 1

Description Describes the agent (drug, food, chemical agent, etc) that is responsible for the adverse reaction
Value Domain String
target Used by 3 transactions, one template, inherited once
 
draft Agent Code 0 … 1
epsos-dataelement-72
Id epsos-dataelement-72 (2013‑05‑31)
Cardinality 0 … 1

Description The code of the allergen agent
Value Domain Code
Choice list
Concept List

Value Set epSOSAllergenNoDrugs (version DYNAMIC)

Value Set epSOSWHO-ATC (version DYNAMIC)
target Used by 3 transactions, one template, inherited once
 
folder draft Pregnancy History 0 … *
epsos-dataelement-115
Id epsos-dataelement-115 (2013‑05‑31)
Cardinality 0 … *

target Used by 3 transactions, one template, inherited 0 times
 
draft Expected date of delivery 0 … 1
epsos-dataelement-116
Id epsos-dataelement-116 (2013‑05‑31)
Cardinality 0 … 1

Description Date in which the woman is due to give birth. Year, day and month are required.
Terminology Asscociation This concept is represented by code "11778-8" (Delivery date Clinical.estimated) from code system 2.16.840.1.113883.6.1 LOINC
Terminology Asscociation This concept is represented by code "11779-6" (Delivery date Estimated from last menstrual period) from code system 2.16.840.1.113883.6.1 LOINC
Terminology Asscociation This concept is represented by code "11780-4" (Delivery date Estimated from ovulation) from code system 2.16.840.1.113883.6.1 LOINC
Terminology Asscociation This concept is represented by code "11781-2" (Delivery US.composite.estimated) from code system 2.16.840.1.113883.6.1 LOINC
Value Domain Date
Property
Timestamp precision
at least day, month and year
Example 01/01/2010
target Used by 3 transactions, one template, inherited 0 times
 
folder draft Social History 0 … *
epsos-dataelement-111
Id epsos-dataelement-111 (2013‑05‑31)
Cardinality 0 … *

target Used by 3 transactions, one template, inherited 0 times
 
folder draft Social History Observations 0 … *
epsos-dataelement-112
Id epsos-dataelement-112 (2013‑05‑31)
Cardinality 0 … *

target Used by 3 transactions, one template, inherited 0 times
 
draft Social History Observations related to: smoke, alcohol and diet 0 … 1
epsos-dataelement-113
Id epsos-dataelement-113 (2013‑05‑31)
Cardinality 0 … 1

Value Domain Code
Choice list
Concept List

Value Set epSOSSocialHistory (version DYNAMIC)
Example cigarette smoker
Example alcohol consumption
target Used by 3 transactions, one template, inherited 0 times
 
draft Date range of observation 0 … 1
epsos-dataelement-114
Id epsos-dataelement-114 (2013‑05‑31)
Cardinality 0 … 1

Value Domain String
Example 1974 to 2004
target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Document Data 1 … 1 Mandatory
epsos-dataelement-62
Id epsos-dataelement-62 (2013‑06‑03)
Cardinality 1 … 1 Mandatory

Description Information about the document itself
target Used by 10 transactions, 0 templates, inherited 0 times
 
draft Identification 1 … 1 Mandatory
epsos-dataelement-176
Id epsos-dataelement-176 (2013‑10‑22 14:47:34)
Cardinality 1 … 1 Mandatory

Description Identification of the document
Value Domain Identifier
target Used by 5 transactions, one template, inherited 0 times
 
draft Type 1 … 1 Mandatory
epsos-dataelement-296
Id epsos-dataelement-296 (2013‑11‑27 14:10:56)
Cardinality 1 … 1 Mandatory

Description Type of the document
Value Domain Code
Choice list
Concept List

Value Set epSOSDocumentCode (version DYNAMIC)
target Used by 8 transactions, one template, inherited 0 times
 
draft Confidentiality 0 … 1 Required
epsos-dataelement-297
Id epsos-dataelement-297 (2013‑11‑27 14:11:34)
Cardinality 0 … 1 Required

Description Confidentiality of the document as a whole
Value Domain Code
Choice list
Concept List

Value Set epSOSConfidentiality (version DYNAMIC)
target Used by 5 transactions, one template, inherited 0 times
 
draft Language 1 … 1 Mandatory
epsos-dataelement-298
Id epsos-dataelement-298 (2013‑11‑27 14:12:11)
Cardinality 1 … 1 Mandatory

Description The principal language of the document
Operationalization The language code SHALL be in the form nn-CC. The nn portion SHALL be an ISO-639-1 language code in lower case derived by the Value Set epSOSLanguage. The CC portion SHALL be an ISO-3166 country code in upper case derived by the value Set epSOSCountry
Value Domain Code
Example
English in United Kingdom
en-GB
Example
Dutch in The Netherlands
nl-NL
Example
Dutch in Belgium
nl-BE
Example
German in Germany
de-DE
Example
German in Austria
de-AT
target Used by 5 transactions, one template, inherited 0 times
 
draft Country A 1 … 1 Mandatory
epsos-dataelement-63
Id epsos-dataelement-63 (2013‑06‑03)
Cardinality 1 … 1 Mandatory

Description Name of country A
Value Domain Code
Choice list
Concept List

Value Set epSOSCountry (version DYNAMIC)
Example United Kindom
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft Topicality 1 … 1 Mandatory
epsos-dataelement-64
Id epsos-dataelement-64 (2013‑06‑03)
Cardinality 1 … 1 Mandatory

target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Date Created 1 … 1 Mandatory
epsos-dataelement-65
Id epsos-dataelement-65 (2013‑06‑03)
Cardinality 1 … 1 Mandatory

Description Date on which the document was generated
Value Domain Date+time
Property
Timestamp precision
at least day, month and year
Example 01/01/2009
target Used by 5 transactions, one template, inherited 0 times
 
folder draft Author 0 … 1
epsos-dataelement-67
Id epsos-dataelement-67 (2013‑06‑03)
Cardinality 0 … 1

Description To highlight if the data is collected manually by an HP or is collected automatically from different sources (eg: hospital doctor repository, GPs...etc) through predetermined clinical rules.
target Used by 5 transactions, one template, inherited 0 times
 
draft Author Identification 1 … 1 Mandatory
epsos-dataelement-22
Id epsos-dataelement-22 (2013‑06‑03)
Cardinality 1 … 1 Mandatory

Description Unique identification of the Health Professional.
Value Domain Identifier
target Used by 5 transactions, one template, inherited 0 times
 
folder draft Author Full Name 1 … 1 Mandatory
epsos-dataelement-19
Id epsos-dataelement-19 (2013‑06‑03)
Cardinality 1 … 1 Mandatory

Description The full name of the Health Professional
target Used by 5 transactions, one template, inherited 0 times
 
draft Given Name 1 … 1 Mandatory
epsos-dataelement-20
Id epsos-dataelement-20 (2013‑06‑03)
Cardinality 1 … 1 Mandatory

Description The Name of the HP (Example: John). This field can contain more than one element
Value Domain String
Example John
target Used by 5 transactions, one template, inherited 0 times
 
draft Family Name/Surname 1 … 1 Mandatory
epsos-dataelement-21
Id epsos-dataelement-21 (2013‑06‑03)
Cardinality 1 … 1 Mandatory

Description This field can contain more than one element.
Value Domain String
Example Español Smith
target Used by 5 transactions, one template, inherited 0 times
 
draft Prefix 0 … 1
epsos-dataelement-273
Id epsos-dataelement-273 (2013‑11‑27 11:47:15)
Cardinality 0 … 1

Value Domain String
target Used by 4 transactions, one template, inherited 0 times
 
draft Suffix 0 … 1
epsos-dataelement-274
Id epsos-dataelement-274 (2013‑11‑27 11:47:25)
Cardinality 0 … 1

Value Domain String
target Used by 4 transactions, one template, inherited 0 times